﻿<div class="col-md-11 bank-card-form">
    <div class="panel panel-default">
        <div class="panel-heading">
            <h4 style="display: inline-block;">Card information</h4>
            <div class="row" style="margin-top: 0;">
                <div class="col-md-12">
                    <span class="help-block small-font">Card number</span>
                    <input class="form-control" id="checkout_card_number" name="checkout[card_number]" required="required" type="text" />
                </div>
            </div>
            <div class="row" style="margin-bottom: 15px; margin-top: 20px;">
                <div class="col-md-4">
                    <span class="help-block small-font">Expiration date</span>
                    <select class="form-control" id="checkout_card_expiration_month" name="checkout[card_expiration_month]"></select>
                </div>
                <div class="col-md-4">
                    <span class="help-block small-font">&nbsp;</span>
                    <select class="form-control" id="checkout_card_expiration_year" name="checkout[card_expiration_year]"></select>
                </div>
                <div class="col-md-4">
                    <span class="help-block small-font">CVV</span>
                    <input class="form-control" id="checkout_card_cvv" name="checkout[card_cvv]" required="required" type="text" />
                </div>
            </div>
        </div>
    </div>
</div>